Healthcare Provider Details

I. General information

NPI: 1639641350
Provider Name (Legal Business Name): CINDY C JACOBS MEDICAL TECHNOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 12/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CANYON LAKE DR
RAPID CITY SD
57702-8114
US

IV. Provider business mailing address

3200 CANYON LAKE DR
RAPID CITY SD
57702-8114
US

V. Phone/Fax

Practice location:
  • Phone: 605-355-2228
  • Fax: 605-355-2514
Mailing address:
  • Phone: 605-355-2228
  • Fax: 605-355-2514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number04005569
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5549050
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerMEDICAID
# 2
Identifier0140070
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: